10 things emergency rooms won’t tell you

Why it takes so long and costs so much to get care in the E.R.

By

JonnelleMarte

1. “Patience will get you nowhere.”

Nobody likes a visit to the emergency room. Babies are crying. People are wheezing or moaning in pain. And there’s little relief in watching the worst cases being rushed to an operating room. Nonetheless, more people step into ERs every year, with visits hitting 130 million in 2010, up 34% from 97 million in 1995, according to the Centers for Disease Control. Meanwhile, the number of emergency departments is down about 11% over that same time period.

Jim Haynes

As a result, people are waiting longer to see a doctor: A 2009 report from the Government Accountability Office found that patients whose condition indicated they should have been seen in 1 to 14 minutes, according to Emergency Nurses Association guidelines, waited 37 minutes on average to see a physician. Even worse, those who were supposed to be seen in less than 1 minute were left waiting for about 28 minutes. Crowding can be worse during the holidays, when some hospitals see an uptick in visits from patients suffering from heart disease or from excess alcohol consumption.

Hospitals are addressing the crowding by assigning more responsibilities to physician assistants and nurse practitioners and treating some patients without assigning them to a bed. Some hospitals are treating patients more quickly by using a team approach where patients are attended to by a doctor, nurse and registration worker at once who can immediately order needed tests and procedures as well as quickly treat patients with simple cases, says Alex Rosenau, president of the American College of Emergency Physicians, or ACEP, a trade group for emergency physicians.

The urgency of a patient’s condition is determined when he or she first walks into the ER and is seen by a nurse in a process known as triage, which is designed to get the sickest and most seriously injured patients in front of a doctor first. But because sudden changes in a person’s condition can go unnoticed amid the commotion in crowded emergency rooms, it’s important for patients or their advocates to speak up if they begin to feel much worse or if they think doctors or nurses are misunderstanding their symptoms, says Rosenau.

2. “But shorter wait times aren’t always better.”

More hospitals are advertising their wait times—on their websites, on Twitter and even on billboards—in an effort to set themselves apart from competitors. And lowering wait times could also protect their bottom lines: Because of a pay-for-performance system created by the Affordable Care Act, Medicare payments to hospitals are partly based on patient satisfaction. See also: U.S. ties hospital payments to making patients happy.

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Children's hospitals and clinics are turning to new devices and programs to help with the scary and painful part of medical care for kids. Laura Landro and Cardon Children's Medical Center's Rhonda Anderson and Mindy Mesneak explain. Photo: Mission Children’s Hospital.

The advertised wait times might help patients make smarter decisions about where to go for non-urgent conditions, doctors say, but some providers are concerned that this recent focus on the clock could end up hurting patients. “You can move people through quicker, but if you are taking short cuts, there is a cost,” says Drew Fuller, an emergency medicine physician in Maryland and director of safety innovation for Emergency Medicine Associates, a physician group. For instance, if hospitals interrupt care in an effort to move some less-urgent patients through the system, they may be putting high-risk patients in danger, according to an informational paper on wait times by ACEP. And patients who avoid the emergency room because they’re worried about long wait times could be putting themselves at risk, doctors say.

Another issue with publicized wait times: They’re not reliable. Many hospitals measure wait times differently, making it difficult for patients to interpret them. Some hospitals stop the clock at the point when a patient is first greeted, others when a patient is first examined and others when a patient is moved to a room, ACEP points out in its report. And unusually high wait times can occur with little or no notice, doctors say, rending predicted waits inaccurate. “I could advertise my wait time as 20 minutes but then a school bus of children comes in and it’s now an hour and a half,” says Rosenau.

3. “Our riskiest procedure doesn’t involve needles or scalpels.”

hameleonsEye / Shutterstock.com

Some doctors say the most dangerous procedure that happens in the emergency room doesn’t take place anywhere near the operating table: It’s the handoff that happens between doctors and nurses changing shifts or when patients are transferred to another department. If doctors don’t communicate well when they’re changing shifts, insiders say, the most important information about the patient can get lost amid the list of figures and status updates in the patient’s chart, making it difficult for the doctor taking on the patient to know what to prioritize. An estimated 80% of serious medical errors are due to miscommunications between medical providers handing off or transferring patients, according to the Joint Commission, a nonprofit organization which accredits health care organizations in the U.S.

“The fact is that we have no standards out there for how physicians do this critical thing,” says Fuller. Fuller is among the doctors calling for a standardized approach known as “Safer Sign Out.” The process asks doctors and nurses to fill out a form highlighting their biggest concerns about a patient and to meet briefly when they’re transferring shifts to discuss those concerns and introduce the incoming doctor to the patient. Some hospitals are overlapping the first hour of the incoming doctor’s shift with the last hour of the outgoing doctor’s shift in order to give doctors time to do all this, says Rosenau.

4. “We constantly forget to wash our hands.”

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If you’re worried about catching something from the person sneezing next to you in the waiting room, just imagine the germs surrounding the doctor or nurse treating you, say health experts. Health-care workers who don’t wash their hands are putting their patients at risk for urinary tract infections, pneumonia, and blood infections, among other serious complications, doctors say. And emergency room physicians, moving frequently from one urgent patient to another, have more opportunities to forget to wash their hands, says Jason Sanders, a Ph.D. student at the University of Pittsburgh studying epidemiology, or how diseases spread within populations. While health-care workers agree that hand washing can help reduce a patient’s risk of infection, many hospitals are battling low compliance rates. A 2009 analysis of 20 hospital-based studies on hand hygiene by the World Health Organization’s World Alliance for Patient Safety found that hand hygiene often improved when hospitals introduced new guidelines, hand-sanitizer stations and awareness posters, but many health-care workers still washed their hands less than half as often as they were supposed to.

Hospitals are showing patients videos and brochures that encourage them to ask doctors if they’ve washed their hands, but many patients are too intimidated to challenge their doctors. According to a study published in September in the journal Infection Control and Hospital Epidemiology, one third of patients surveyed by the University of Pittsburgh Medical Center said they didn’t see their doctors wash their hands, but two-thirds of that group said nothing to the doctor about it. Some hospitals are posting hand-washing rates around the hospital in an effort to get health-care workers to recognize when they may be forgetting to wash, says Rosenau. Others are watching workers more closely. After North Shore University Hospital in Manhasset, N.Y. began using video surveillance to monitor hand washing in 2008, the share of health-care workers complying with hand-hygiene policies increased from less than 10% to more than 80%, according to the hospital.

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